OB E2 - Post Partum Adaptations PDF

Preview

Summary

OB E2 - Post-Partum Adaptations ChPostpartum Period= The period of time following the delivery of the child during which the body tissues, especially the reproductive system reverts back to the pre-pregnant state , both anatomically and physiologically.  Critical transition period for woman, newbor...

Description

OB E2 - Post-Partum Adaptations Ch15

Postpartum Period = The period of time following the delivery of the child during which the body tissues, especially the reproductive system reverts back to the pre-pregnant state, both anatomically and physiologically.  Critical transition period for woman, newborn, and family physiologically and psychologically  Puerperium: period after delivery of placenta, lasting for 6 weeks  Possible definition: changes in all aspects of mother’s life that occur during the first year following birth of child  Maternal physiologic and psychological changes  Mother and family adjustment to new family member

Puerperium/Postpartum = The puerperium or the postpartum period lasts for 6 weeks.  It is divided into 3 phases: o Immediate Postpartum: the 24-hour period immediately following delivery. o Early Postpartum or puerperium: up to 7 days. o Remote postpartum or puerperium: up to 6 weeks.

Maternal Psychological Adaptation: Reva Rubin’s Three Phases Taking-in phase  Time immediately after birth when the client needs others to meet her needs and relives the birth process; Ex: ask to asleep or eat Taking-hold phase  Second phase characterized by dependent and independent maternal behavior Letting-go phase  Third phase in which woman reestablishes relationships with others

Psychological Changes  Vulnerability  Tremendous challenges  Nurses have a remarkable opportunity to help women learn, gain confidence, and experience growth as they assume the mother identity.

Reproductive System Adaptations  Uterus o Involution = contraction of muscle fibers; catabolism; regeneration of uterine epithelium o Lochia: rubra, serosa, alba o Afterpains  Cervix: closure; now appearing as jagged slit-like opening  Vagina: eventual thickening and return of rugae  Perineum: laceration or bruise will heal

Question: Is the following statement True or False? After birth, the cervix returns to its prepregnant shape. a. True b. False

Postpartal Physical Adaptations Uterus  At delivery  fundus is at the umbilicus

 1-2 hours: midway between umbilicus and symphysis pubis  12 hours: 1 cm above or at umbilicus  After that  the height of the uterine fundus decreases (involutes) by approximately 1 cm per day  What to assess o Should remain firm at all times; Boggy-soft  massage to keep it firm o Blood and clots formation o Failure of uterus to contract  check if something is left behind o If off to the side  suspect full bladder  Subinvolution = the failure of the uterus to return to a nonpregnant state o Noted by when nurse can still feel the uterus after about 10 days o Common causes  retained placental fragments or infection Lochia  Rubra (red) o 3 days o blood, fragments of decidua, mucus  Serosa (pinkish or brownish red) o days 4-9 o blood, mucus, invading leucocytes  Alba (white or yellowish mucus) o day 10 to 3-6 weeks o mostly mucus, high in leukocytes ex: if a lady says she still has her period 2 weeks after she gave birth  suspect something is wrong because at 2 weeks after giving birth, the lochia should be alba know the lochia**

(know this)  Lochia Measurement o Scant - less than 1” per hour on pad o Light - 1-4” per hour on pad o Moderate - greater than 4” per hour on pad o Heavy - pad saturated in 1-2 hours o Hemorrhage - saturated pad in 15 min Requires immediate action o Clots - quarter size or less are OK o Large Clots are not normal

Afterpains  Intermittent uterine contractions that are felt  More common in multiparas than primiparas o If the lady had a twin  the uterine is more stretched than lady just with one baby  the contractions will be stronger and longer in duration  May cause the mother severe discomfort for 2-3 days after birth  Breastfeeding also increases the frequency and severity of afterpains

Post-partal Nursing Assessment      

Physical assessment M-mental status A- auscultation B- breast U- uterus B- bladder

   

B- bowel L- lochia E- episiotomy, epidural site H- hemorrhoids, homan’s sign

Recognize alterations and significance Vital signs: Pulse, blood pressure: first 24 hours postpartum

Vital signs  Temperature elevations due to normal process should last up to 24 hours  Do not worry + just give fluids o If temperature is elevated for more than 24 hours  suspect infection o If elevated consider the time since birth to determine dehydration/infection o If elevation is associated with symptoms assess history  Blood pressure should remain stable  Pulse rate slows  no cause for alarm

Breasts  Assess  symmetry, consistency, lumps  Engorgement o breasts, nipples, or both hard and distended with congestion and accumulation of milk

 Assess nipples o for intactness o note signs of redness, bruising, or cracking o colostrum is expected  Suction pressure on nipple  Cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman are generally indications that the baby is improperly positioned on the breast  Woman not breastfeeding; assess nipples for any discharge, lumps, or hardness o Get a well-fitted supportive bra and avoid stimulating breast

Lactation  Secretion of milk by the breasts o Colostrum = the first form of milk produced by the mammary glands of immediately following delivery of the newborn.  Result of interaction of progesterone, estrogen, prolactin, and oxytocin  Typically, real milk appearing 4 to 5 days after childbirth o Colostrum coming out first  “Breast crawl” process o Every newborn has the ability to find the mother’s breast when placed on the mother’s abdomen Engorgement = Process of swelling of the breast tissue due to an increase in blood and lymph supply as a precursor to lactation  Relieved by frequent emptying, warm showers and compresses before feeding, cold compresses between feedings, if breast-feeding

 if not breast-feeding  Tight supportive bra, ice, avoidance of breast stimulation Question: For the woman who is not breast-feeding her newborn, which measure would be most appropriate to relieve engorgement? a. Warm showers b. Nipple stimulation c. Ice to the breasts d. Manually expressing milk

Ovulation and Return of Menstruation  Interplay of hormones: estrogen, progesterone, prolactin, and oxytocin  Nonlactating women: return of menstruation 7 to 9 weeks after birth  Lactating women: return dependent on breast-feeding frequency and duration; anywhere from 2 to 18 months Assessment of Episiotomy  Episiotomy o Intact o ML = midline o RML = Right medio-Lateral o LML = Left Medio-Lateral  Assessment of Perineum: “R.E.E.D.A.” o Redness

o o o o

Edema Ecchymosis Discharge Approximation

Laceration  “Skid Mark” - not through the skin  1st degree - skin & mucus membrane  2nd degree - skin, mucus membrane, muscle  3rd degree - all the above, plus anus  4th degree - all the above plus the anterior wall of rectum *(3rd & 4th may require special diet or Laxative, depending on facility procedure) Uterus Check for:  Fundal height and tone  position of fundus in relation to the umbilicus o If palpable above level of umbilicus or to the right  full bladder

o Encourage woman to void before assessment o boggy or very soft in the abdomen  Poorly contracted uterus  massage till it’s firm o assess for involution after the birth  going back into the pelvis + descending by 1 cm per day should not be able to feel the uterus anymore at day 10 after birth

Cardiovascular System Adaptations  Blood volume and cardiac output  Hematocrit level  Pulse rate and blood pressure  Coagulation factors  Red blood cell production Tell patient to continue taking prenatal vitamin after the delivery. Question: Is the following statement True or False? The drop in maternal blood volume after birth leads to a similar drop in hematocrit. a. True b. False

Urinary System Adaptations  Glomerular filtration rate and renal flow increase  Voiding sensation affected by: o Perineal lacerations o Generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus o Hematomas o Decreased bladder tone due to regional anesthesia o Diminished sensation of bladder pressure due to swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor  Causes of Postpartum Diuresis o Large amounts of IVF given during labor o Decreasing antidiuretic effect of oxytocin as its level declines o Buildup and water retention of extra fluids during pregnancy o Decreasing production of aldosterone (the hormone that decreases sodium retention and increases urine production) SELECT ALL?? Post partal assessment - Bladder Assess amount, frequency, and any difficulties initiating voiding (Normally, at least pass 30 ml/hour; in 24 hours  pass 720 ml at least)  Pressure on bladder: perineal trauma, edema  Urinary frequency: diuresis  Palpate bladder: assess for adequate emptying (full bladder could cause a displacement of the uterus)

GI System Adaptations  The GI system quickly returns to normal o Relief of pressure on organs  Decreased bowel tones for several days  Decreased peristalsis occurs

 Constipation is common due to fear of straining affecting the perineum + dehydrated o Increase fiber and fluid o Increase activities  Hunger and thirst occur due to NPO status prior to delivery Post partal assessment – Bowel  Auscultate abdomen for bowel sounds  Audible in all four abdominal quadrants  Inquire about bowel movement  Client concern: discomfort or pain  Assess for hemorrhoids o Give fiber and fluids

Musculoskeletal System Adaptations  Joints return to prepregnant state except for feet  Women commonly experience fatigue and activity intolerance for weeks after giving birth  Abdominal muscle tone is diminished after birth and special exercises are needed to return to normal o Ex: Diastasis recti 

Integumentary System Adaptations  Pigmentation fades o Ex: linea nigra, melasma are going to fade  Stretch marks fade to silvery lines  Diaphoresis is common for about a week postpartum

Respiratory System Adaptations  Tidal volume, minute volume, vital capacity, and functional residual capacity return to prepregnant values within 1 to 3 weeks of birth  Anatomic changes reside quickly o Thoracic cavity had little space due to the abdominal cavity taking all the spaces after birth, the thoracic cavity will go back to normal

Endocrine System Adaptations    

Estrogen and progesterone levels drop quickly Placental hormones decline rapidly Prolactin levels decline within 2 weeks if NOT breast-feeding Oxytocin reflex and prolactin helps with breast feeding

Self-Care Measures  Afterpains are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens the contractions.  Mild analgesics can reduce this discomfort.  Failure to maintain and restore perineal muscular tone leads to urinary incontinence later in life for many women.  kegel exercise (instruct the lady to pee + contract/stop, then repeat to gain control of pelvic muscle)  Anticipate the woman’s need to replenish her body with food and fluids.  If rectus muscle tone is not regained through exercise, support may not be adequate during future pregnancies.

Multicultural Family  Postpartum beliefs, practices, customs  Nurses must be open, respectful, nonjudgmental  Differences in beliefs o Balance hot and cold o Confinement after childbirth

Engrossment: Partner Psychological Adaptation        

Visual awareness of the newborn Tactile awareness of the newborn Perception of the newborn as perfect Strong attraction to the newborn Awareness of distinct features of the newborn Extreme elation by the father Increased sense of self-esteem Three-stage role development process o Expectations o Reality o Transition to mastery

Maternal Psychological Adaptations  Attachment: formation of a relationship between a parent and his or her newborn through a process of physical and emotional interactions  Early and sustained contact between newborns and parents is vital  Nurses play a crucial role in assisting with this process of attachment  Factors influencing attachment include environmental circumstances, newborn health, and quality of nursing care

Postpartum Mood Disorders Baby Blues  Mild depressive symptoms, anxiety irritability, mood swings, tearfulness, increased sensitivity, fatigue  Usually peak at days 4 and 5 and resolve by day 10, if it continues on 10 days  make sure the mom is not left alone with the infant Postpartum depression and psychosis  Symptoms last longer and are more severe and require treatment  May lead to poor bonding, alienation from loved ones, daily dysfunction, and violent thoughts/actions

Variables Affecting Maternal Role Attainment Maternal  Confidence, age, relationship with father, socioeconomic status, birth experience, stress, support system, personality traits, self-concept, childrearing attitudes, role strain, health status, preparation during pregnancy, relationship with own mother depression, and anxiety Infant  Appearance, responsiveness, temperament, health status

Four Stages of Becoming A Mother (BAM)  Commitment, attachment to unborn baby, preparation for delivery and motherhood during pregnancy  Acquaintance/attachment to infant, learning to care for infant, and physical restoration 2 to 6 weeks postbirth  Moving toward a new normal  Achievement of a maternal identity through redefining self to incorporate motherhood (around 4 months)...